February Informed Newsletter 2023

As the Calendar Marches Onward

It’s hard to believe we’re already nearing the end of February. It seems like just yesterday we were wishing you a happy Thanksgiving, holiday season and New Year’s. Just like the calendar, your hard work never pauses – and we simply can’t express our gratitude enough. Thank you for taking such constant, dedicated, world-class care of our members’ health. As we march into March, we’re grateful for you.

As It Relates to You

Key Information for You and Your Staff

Announcing Our New and Improved Member Account
and Member Mobile App

Earlier this month, we launched a new member account and mobile app for members of our health plans. We took this step to create a much better experience for them, giving them enhanced security, improved service, and a more streamlined connection between their health plan and their providers – since the new member account and mobile app are supported by MyChart. We’d love your help spreading the word about this exciting launch. If your patients (who are members of our health plans) want to learn more or have questions about the new member account and app, let them know to call us at the number on the back of their health plan ID card. Thank you.

***

Help us move the needle.

Together we can help people live their healthiest lives. Find reminders, tips and more in this section, to guide improvements in patient outcomes. Help us move the needle.

Closing Gaps in Care: New Year, New Gaps to Close

It’s hard to believe, but 2023 is already here to stay. As we progress into the new year, it’s important to make sure your patients are getting the appropriate preventive services needed in order to identify any issues and close any gaps in their care. As appropriate, please remind your patients about the following screenings.

All Patients:

• Colorectal cancer screening.
• Blood pressure reading.
• Statins therapy for patients with clinical atherosclerosis.
• Seasonal flu vaccine.
• Medication review.

Women:

• Breast cancer screening.
• Cervical cancer screening.
• Osteoporosis screening for women who’ve had a fracture.
• Prenatal and postpartum care for pregnant women and those who’ve just given birth.

Patients with Diabetes:

• A1C test.
• Nephropathy screening.
• Diabetic retinal eye exams.

Patients with Rheumatoid Arthritis:

• Treatment with a disease-modifying antirheumatic drug (DMARD).

Also, please remember we have health coaching and care coordination services that can help your patients (who are members of one of our health plans) manage their conditions at no extra cost to them. We know you worry about your patients’ health between visits, and these services can help improve their health outcomes throughout the entire year.

It’s not too late to get a flu shot.

As healthcare providers, you know how important flu shots are to your patients, their families and the community in general. This winter and early spring, they’re more essential than ever due to the ongoing COVID-19 pandemic. Flu shots are especially important for those at high risk from influenza, many of whom are also at high risk for contracting COVID-19 or developing serious outcomes if they do.

Remind your patients that it’s not too late to get their flu shot. It varies according to health plan, but flu shots are covered at no cost to the member in most cases. Your patients can call the number on the back of their member ID card to learn more about costs and where they can go to get their vaccinations. Together we can help keep our community healthy and well.

Remind your young patients to get their yearly wellness visit.

Families trust their doctors and healthcare providers – for good reason – and your advice matters more than you probably realize. Help us encourage parents and guardians to schedule their children’s yearly wellness checkups – and even remind teen and young adult patients themselves. This is an important action that’ll help keep your young patients healthy and well.

Some Background Information:

• Yearly wellness visits are the best way to catch health issues early – which leads to more effective treatment.
• These visits are a great way to make sure your young patients are healthy and vaccinated for the upcoming school year and sports seasons.
• We track how often our young members are seen for their yearly wellness checkups. Our goal? We’d love to see more members getting their checkups each and every year.
• We’re sending out educational and reminder materials via email and mail. These focus on the benefits of yearly wellness visits for our young members.

As always, we’re deeply thankful for your partnership in efforts like these – and for all the work you and your staff do to help keep our young members healthy. Click here – and under Tip Sheets click on Quality Measure Tip Sheets – to find more tips on well-child visits.

Help prevent and control cardiovascular disease.

Your actions can help patients prevent cardiovascular disease – or manage their conditions if they have it. Here are a few top-line tips from The Guide to Community Preventive Services, a collection of evidence-based findings of the Community Preventive Services Task Force (a part of the U.S. Department of Health and Human Services).

• Put in place clinical decision-support systems at the point of care. Clinical decision-support systems allow you to screen for cardiovascular disease risk factors, assess a patient’s risk level and alert them (during their visit) when health indicators for cardiovascular disease risk factors are elevated.
• Use team-based care. Create – and use – a full healthcare team that works together to improve your patients’ care. This coordinated team should include the patient, their family, the patient’s primary care provider and other health professionals as needed for their unique conditions (specialists, nurses, pharmacists, dietitians, etc.).
• Lower your patients’ out-of-pocket costs. Help your patients find lower-cost options for medicines to control their high blood pressure, high cholesterol and other cardiovascular conditions. Some patients don’t take needed medications if they can’t afford the costs.

For more information, click here to see all Task Force findings and recommendations on preventing cardiovascular disease.

Diabetes 101: Promote medication management for your patients.

Medications are important for every patient – and even more-so for those with diabetes. Using these tips from the CDC, help your patients with diabetes take, manage and get the most out of their medications.

• Work closely with your patients’ pharmacists. Partner directly with them to identify, prevent and resolve any medication-related issues. The CDC calls this care provider-pharmacist partnership collaborative drug therapy management (CDTM). It’ll help your patients get the most benefit from their drugs. Pharmacists can also advise your patients about how to properly take their medicines and about potential options for lower-cost alternatives. Finally, they can play a key role in getting them needed vaccines, such as those for flu, pneumococcal disease and hepatitis B.
• Know the common risks. Many people with diabetes have problems with properly managing their medications. They’re frequently at high risk for drug-related problems since they often have a variety of health issues, take multiple medicines, see a variety of different healthcare providers and get their drugs from multiple sources.
• At every visit, ask your patients questions about their medicines. Make sure they have all the information they need – and that they’re staying up to date on taking their drugs as prescribed.
• Remind them to keep their blood glucose, blood pressure and blood lipids under control. Give help as needed.
• Refer your patients to diabetes self-management education and support (DSMES) services. These provide extra levels of great help.

HEDIS Quality Measure – Prenatal and Postpartum Care (PPC)

By working together, we can improve the timeliness of prenatal and postpartum care for your patients. The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a set of standards that helps us together assess the care patients receive. This article gives you information on the HEDIS quality measure for prenatal and postpartum care, and tips on how to meet this measure and provide best care.

Why’s this measure important?

Every year in the U.S., about 4 million women give birth – and 1 million of these will have complications during their pregnancy, labor and delivery, or postpartum period. As many as 60% of all pregnancy-related deaths could be prevented – according to some studies – if women had better access to care, received higher quality healthcare and made certain lifestyle changes. The bottom line? High-quality, timely prenatal and postpartum care can help prevent and manage complications, save lives, and set both mothers and babies on track for better long-term health.

What’s the HEDIS measure?

HEDIS looks at, and reports, the following:

1. Timeliness of Prenatal Care: The percentage of deliveries of live births in which women had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization.
2. Postpartum Care: The percentage of deliveries of live births in which women had a postpartum visit on or between seven and 84 days after delivery.

Thank you for all the hard work you do to help keep our members – mothers, babies and all others – healthy and well. Click here – and under Tip Sheets click on Quality Measure Tip Sheets – to find more tips on prenatal and postpartum visits.

HEDIS Chart Reviews for 2023 (Measurement Year 2022)

We want our healthcare coverage to be the best. As the previous article alludes to, we collect data for HEDIS (the Healthcare Effectiveness Data and Information Set) to see how we measure up against national averages. This data collection and analysis is required for National Committee for Quality Assurance (NCQA) accreditation, and it shows us where we need to focus our quality efforts to better serve our members and provider partners.

February begins our 2023 HEDIS data collection season (looking at measurement year 2022), and this initiative will run through June. We count on you to help us obtain the documentation we need to measure our performance:

• We work with you and your office staff to get the documentation we need. Most provider offices and organizations allow us access to their electronic medical record (EMR).
• For offices that don’t have an EMR, we can set up a site visit or fax a request to get the documentation.

If you have any questions about HEDIS, or are interested in setting up remote access, contact our Quality Management department at (217) 902-9493 or (800) 851-3379, ext. 9493. Thank you for your help in this important initiative.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Colorectal Cancer Screening – Recommendations for Black Adults

Compared to other races/ethnicities, Black adults have the highest rates of getting colorectal cancer and dying from it. The causes of this disparity are complex. Recent studies point to inequities in healthcare – specifically in access to, use of, and the quality of colorectal cancer screenings and treatments – as the primary driver, rather than genetic differences.

You can help move the needle. The U.S. Preventive Services Task Force (USPSTF) recommends adults start screening for colorectal cancer at age 45. They also strongly encourage healthcare providers to take steps to make sure their Black patients (and indeed all patients age 45 and above) get, and stay up to date with, their recommended colorectal cancer screenings, follow-up care and treatments. Patients trust their doctors and providers, and even a simple reminder can push people to schedule the screenings they need. Finally, the USPSTF also encourages the development of coordinated systems of care, with special attention given to Black communities, to make sure all adults receive high-quality care across the continuum of screening and treatment. For more information, click on the helpful reference below.

Reference Used for This Article:

U.S. Preventive Services Task Force, “Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement,” JAMA Network^TM, 18 May 2021.

Schizophrenia, Medication Adherence and the Health Belief Model

Schizophrenia is very serious, but you can help your patients deal with this mental health disorder. Here are things to know and do:

• Medication is considered the most effective treatment.
• However, nearly half of all patients with schizophrenia don’t adhere to their prescribed medication treatment.
• You can play an active role in making sure your patients take their medicine as prescribed:
  • Use the Health Belief Model to make decision-making more patient-centered. Chat with your patients about their two available options: life with the medication vs. life without it. Share the positive and negative consequences of each option. Let them decide, with you by their side, which option they prefer. And then help them follow through on their decision, by providing education, resources, advice and support. See here for more information about the Health Belief Model.
  • Share decision-making with your patients. Let them know why you’re picking a certain medication and how it will help them. Make them feel involved in the process.
  • Pay close attention to how well the medicine’s working for your patients. Make any adjustments as needed, and let them know why you’re making changes.
  • Talk with your patients about their support system, home environment and other social factors that might help or harm medication adherence.
  • Know about barriers that might be preventing your patients from adhering to their medication treatment – things such as high costs of drugs, lack of transportation to the pharmacy, forgetfulness, poor understanding of how the medicines work and poor support systems.

With your guidance, patients with schizophrenia can get the help and support they need to better adhere to the medications that can bring great benefits to their lives. Thank you.

Reference Used for This Article:

Martijn J. Kikkert, PhD, and Jack Dekker, PhD, “Medication Adherence Decisions in Patients With Schizophrenia,” Psychiatrist.com, 7 December 2017.

***

Updates to High Cost Medical Drugs List

See the table below for changes to the High Cost Medical Drugs List with effective dates.

Note: Medications removed from the High Cost Medical Drugs List may still require prior authorization.

Note: This article/table does not apply to Medicare plans.

Note: This article/table does not apply to Reid Health Alliance Medicare branded plans.

Midwest – Pharmacy Updates

All Plans

New Drug Reviews/Policies

• Relyvrio (sodium phenylbutyrate/taurursodiol)—Treatment of amyotrophic lateral sclerosis in adults
  • Formulary placement recommendations
    • Commercial—Tier 6, Specialty Pharmacy with PA and MDL
    • Medicare—Non-Formulary
• Zoryve (roflumilast)—Topical treatment of plaque psoriasis in patients age 12 years or older
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA and MDL
    • Medicare—Non-Formulary
• Vtama (tapinarof)—Topical treatment of plaque psoriasis in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA and MDL
    • Medicare—Non-Formulary
• Sotyktu (deucravacitinib)—Treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA and MDL
    • Medicare—Non-Formulary
• Recorlev (levoketoconazole)—(Note: product line extension) Treatment of endogenous hypercortisolemia related to Cushing’s syndrome
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
• Skysona (elivaldogene autotemcel)—Treatment to slow the progression of neurologic dysfunction in male patients 4 to 17 years of age with early, active cerebral adrenoleukodystrophy (CALD)
  • Adding Skysona to Lack of Medical Benefit policy
  • Formulary placement recommendations
    • Commercial—Not Covered
    • Medicare—Not Covered

Commercial

Commercial Criteria Changes*

• Plaque Psoriasis Immunomodulator Therapies policy
  • Add Sotyktu to policy
  • Updated criteria language to trial of one (topical, systemic therapy or phototherapy)
• Medications Excluded due to Lack of Clinical Benefit
  • Added Skysona
• Continuous Glucose Monitors
  • Updated language for new-starts, added legacy logic criteria, and added covered quantities of CGM’s and their components
  • Intent is to place PA back on CGMs on 1/1/23; compliant members will be grandfathered, noncompliant members will be treated as new starts
• Dupixent (dupilumab)
  • Added criteria for prurigo nodularis, updated age criteria for asthma diagnosis, updated references
• Atopic Dermatitis Immunomodulator Therapies
  • Updated language for single step products to clarify only one topical trial required, updated language for double step products to clarify only one topical and one systemic therapy trial required
• Psoriatic Arthritis Immunomodulator Therapies
  • Added age criteria for Stelara, updated criteria language for Xeljanz/Rinvoq, removed Enbrel from quadruple step section
• Ulcerative Colitis Immunomodulator Therapies
  • Updated criteria language for Xeljanz/Rinvoq
• Ankylosing Spondylitis Immunomodulator Therapies
  • Updated criteria language for Xeljanz/Rinvoq
• Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Therapies
  • Updated criteria language for Xeljanz, changed Actemra and Orencia to double step and updated criteria language for Kineret

Commercial Tier Changes

Positive Changes

• Fingolimod: Move from Non-Preferred Specialty Pharmacy to Preferred Specialty Pharmacy
  • New generic product released, moving to Preferred tier to align with other generics

Negative Changes—Effective 1/1/2023 (Members were notified.)

• Relexxii 72mg ER: Move from Non-Preferred generic to Non-Preferred brand
  • Branded methylphenidate ER product, moving to align with other branded products
• Methylphenidate ER 72mg (MSC M): Move from Non-Preferred generic to Non-Preferred brand
  • Branded generic product, moving to align with other branded products

*Members currently utilizing these therapies will not experience a disruption.

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• February Meeting: Oncology, Hematology, Infectious Disease.
• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Northwest – Pharmacy Updates

All Plans

New Drug Reviews/Policies

• Relyvrio (sodium phenylbutyrate/taurursodiol)—Treatment of amyotrophic lateral sclerosis in adults
  • Formulary placement recommendations
    • WA Individual—Tier 6, Specialty Pharmacy with PA and MDL
    • Medicare—Non-Formulary
• Zoryve (roflumilast)—Topical treatment of plaque psoriasis in patients age 12 years or older
  • Formulary placement recommendations
    • WA Individual—Non-Preferred Brand with PA and MDL
    • Medicare—Non-Formulary
• Vtama (tapinarof)—Topical treatment of plaque psoriasis in adults
  • Formulary placement recommendations
    • WA Individual—Non-Preferred Brand with PA and MDL
    • Medicare—Non-Formulary
• Sotyktu (deucravacitinib)—Treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy
  • Formulary placement recommendations
    • WA Individual—Non-Preferred Specialty Pharmacy with PA and MDL
    • Medicare—Non-Formulary
• Recorlev (levoketoconazole)—(Note: product line extension) Treatment of endogenous hypercortisolemia related to Cushing’s syndrome
  • Formulary placement recommendations
    • WA Individual—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
• Skysona (elivaldogene autotemcel)—Treatment to slow the progression of neurologic dysfunction in male patients 4 to 17 years of age with early, active cerebral adrenoleukodystrophy (CALD)
  • Adding Skysona to Lack of Medical Benefit policy
  • Formulary placement recommendations
    • WA Individual—Not Covered
    • Medicare—Not Covered

WA Individual

WA Individual Criteria Changes*

• Plaque Psoriasis Immunomodulator Therapies policy
  • Add Sotyktu to policy
  • Updated criteria language to trial of one (topical, systemic therapy or phototherapy)
• Medications Excluded due to Lack of Clinical Benefit
  • Added Skysona
• Continuous Glucose Monitors
  • Updated language for new-starts, added legacy logic criteria, and added covered quantities of CGM’s and their components
  • Intent is to place PA back on CGMs on 1/1/23; compliant members will be grandfathered, noncompliant members will be treated as new starts
• Dupixent (dupilumab)
  • Added criteria for prurigo nodularis, updated age criteria for asthma diagnosis, updated references
• Atopic Dermatitis Immunomodulator Therapies
  • Updated language for single step products to clarify only one topical trial required, updated language for double step products to clarify only one topical and one systemic therapy trial required
• Psoriatic Arthritis Immunomodulator Therapies
  • Added age criteria for Stelara, updated criteria language for Xeljanz/Rinvoq, removed Enbrel from quadruple step section
• Ulcerative Colitis Immunomodulator Therapies
  • Updated criteria language for Xeljanz/Rinvoq
• Ankylosing Spondylitis Immunomodulator Therapies
  • Updated criteria language for Xeljanz/Rinvoq
• Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Therapies
  • Updated criteria language for Xeljanz, changed Actemra and Orencia to double step and updated criteria language for Kineret

WA Individual Tier Changes

Positive Changes

• Fingolimod: Move from Non-Preferred Specialty Pharmacy to Preferred Specialty Pharmacy
  • New generic product released, moving to Preferred tier to align with other generics

Negative Changes—Effective 1/1/2023 (Members were notified.)

• Relexxii 72mg ER: Move from Non-Preferred generic to Non-Preferred brand
  • Branded methylphenidate ER product, moving to align with other branded products
• Methylphenidate ER 72mg (MSC M): Move from Non-Preferred generic to Non-Preferred brand
  • Branded generic product, moving to align with other branded products

*Members currently utilizing these therapies will not experience a disruption.

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• February Meeting: Oncology, Hematology, Infectious Disease.
• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Carle – Pharmacy Updates

All Plans

New Drug Reviews/Policies

• Relyvrio (sodium phenylbutyrate/taurursodiol)—Treatment of amyotrophic lateral sclerosis in adults
  • Formulary placement recommendations
    • Commercial—Tier 6, Specialty Pharmacy with PA and MDL
    • Medicare—Non-Formulary
• Zoryve (roflumilast)—Topical treatment of plaque psoriasis in patients age 12 years or older
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA and MDL
    • Medicare—Non-Formulary
• Vtama (tapinarof)—Topical treatment of plaque psoriasis in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA and MDL
    • Medicare—Non-Formulary
• Sotyktu (deucravacitinib)—Treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA and MDL
    • Medicare—Non-Formulary
• Recorlev (levoketoconazole)—(Note: product line extension) Treatment of endogenous hypercortisolemia related to Cushing’s syndrome
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
• Skysona (elivaldogene autotemcel)—Treatment to slow the progression of neurologic dysfunction in male patients 4 to 17 years of age with early, active cerebral adrenoleukodystrophy (CALD)
  • Adding Skysona to Lack of Medical Benefit policy
  • Formulary placement recommendations
    • Commercial—Not Covered
    • Medicare—Not Covered

Commercial

Commercial Criteria Changes*

• Plaque Psoriasis Immunomodulator Therapies policy
  • Add Sotyktu to policy
  • Updated criteria language to trial of one (topical, systemic therapy or phototherapy)
• Medications Excluded due to Lack of Clinical Benefit
  • Added Skysona
• Continuous Glucose Monitors
  • Updated language for new-starts, added legacy logic criteria, and added covered quantities of CGM’s and their components
  • Intent is to place PA back on CGMs on 1/1/23; compliant members will be grandfathered, noncompliant members will be treated as new starts
• Dupixent (dupilumab)
  • Added criteria for prurigo nodularis, updated age criteria for asthma diagnosis, updated references
• Atopic Dermatitis Immunomodulator Therapies
  • Updated language for single step products to clarify only one topical trial required, updated language for double step products to clarify only one topical and one systemic therapy trial required
• Psoriatic Arthritis Immunomodulator Therapies
  • Added age criteria for Stelara, updated criteria language for Xeljanz/Rinvoq, removed Enbrel from quadruple step section
• Ulcerative Colitis Immunomodulator Therapies
  • Updated criteria language for Xeljanz/Rinvoq
• Ankylosing Spondylitis Immunomodulator Therapies
  • Updated criteria language for Xeljanz/Rinvoq
• Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Therapies
  • Updated criteria language for Xeljanz, changed Actemra and Orencia to double step and updated criteria language for Kineret

Commercial Tier Changes

Positive Changes

• Fingolimod: Move from Non-Preferred Specialty Pharmacy to Preferred Specialty Pharmacy
  • New generic product released, moving to Preferred tier to align with other generics

Negative Changes—Effective 1/1/2023 (Members were notified.)

• Relexxii 72mg ER: Move from Non-Preferred generic to Non-Preferred brand
  • Branded methylphenidate ER product, moving to align with other branded products
• Methylphenidate ER 72mg (MSC M): Move from Non-Preferred generic to Non-Preferred brand
  • Branded generic product, moving to align with other branded products

*Members currently utilizing these therapies will not experience a disruption.

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• February Meeting: Oncology, Hematology, Infectious Disease.
• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Reid – Pharmacy Updates

Medicare

New Drug Reviews/Policies

• Relyvrio (sodium phenylbutyrate/taurursodiol)—Treatment of amyotrophic lateral sclerosis in adults
  • Formulary placement recommendations
    • Medicare—Non-Formulary
• Zoryve (roflumilast)—Topical treatment of plaque psoriasis in patients age 12 years or older
  • Formulary placement recommendations
    • Medicare—Non-Formulary
• Vtama (tapinarof)—Topical treatment of plaque psoriasis in adults
  • Formulary placement recommendations
    • Medicare—Non-Formulary
• Sotyktu (deucravacitinib)—Treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy
  • Formulary placement recommendations
    • Medicare—Non-Formulary
• Recorlev (levoketoconazole)—(Note: product line extension) Treatment of endogenous hypercortisolemia related to Cushing’s syndrome
  • Formulary placement recommendations
    • Medicare—Non-Formulary
• Skysona (elivaldogene autotemcel)—Treatment to slow the progression of neurologic dysfunction in male patients 4 to 17 years of age with early, active cerebral adrenoleukodystrophy (CALD)
  • Adding Skysona to Lack of Medical Benefit policy
  • Formulary placement recommendations
    • Medicare—Not Covered

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• February Meeting: Oncology, Hematology, Infectious Disease.
• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Contact Us

(800) 851-3379, option 3

View as PDF